Nov 14, 2024
Join Dr. Marawar in a conversation with Dr. Anup Patel, and Dr. John Stern, as they discuss the article, "The Tell on Telehealth".
Click here to read the article.
This podcast was sponsored by Marinus Pharmaceuticals.
We’d also like to acknowledge Epilepsy Currents podcast editor Dr. Adriana Bermeo-Ovalle, and the team at Sage.
In episode eight of the Epilepsy Currents Podcast, hosted by Dr. Rohit Marawar, the focus is on telehealth's role in epilepsy care. The episode features insights from Dr. Anup Patel and Dr. John Stern, who co-authored a review article on telehealth. They discuss the evolution of telehealth services, their importance for epilepsy patients, particularly in providing access to specialized care, and the challenges and future of telehealth in clinical practice.
Brief Summary
The podcast delves into how telehealth has become integral to epilepsy care, especially during the COVID-19 pandemic which accelerated its adoption and acceptance. The experts discuss the practicalities of telehealth, including the technological advancements that have made remote healthcare more accessible and effective. They also touch on the regulatory and reimbursement changes that have facilitated its broader use. The episode emphasizes telehealth's role in overcoming geographical barriers to specialized care, making it a critical service for those with mobility restrictions or who live far from epilepsy centers.
Key Takeaways
- Historical Context and Evolution: Dr. Patel highlights that telehealth has been around for over two decades, but significant advances in technology and the necessity brought on by the COVID-19 pandemic have greatly expanded its use. The easing of restrictions around reimbursement during the pandemic also played a crucial role in its widespread adoption.
- Importance for Epilepsy Patients: Dr. Stern points out that beyond the convenience, telehealth is crucial for epilepsy patients due to the driving restrictions often associated with the condition. It allows patients to access specialized care regardless of geographical limitations, enhancing the quality of care they can receive.
- Challenges in Telehealth: Despite its benefits, telehealth presents challenges such as difficulties in performing complete neurological exams, managing neurostimulator devices and managing technological issues from both patient and provider sides. These challenges necessitate a hybrid model of care where telehealth complements, but does not replace, in-person visits.
- Patient Suitability: According to Dr. Patel, while telehealth is ideal for follow-up visits where a physical exam might not be critical, new patients or those needing detailed physical assessments might be better served by in-person visits. This distinction helps in optimizing care delivery based on patient needs.
- Future of Telehealth: Both experts agree that telehealth will continue to be a part of the healthcare landscape. Dr. Stern speculates that future enhancements may include more integrated remote patient monitoring and possibly satellite offices that provide some in-person support functions to complement telehealth visits, which could improve the quality of remote care.
This episode effectively outlines the transformative impact of telehealth on epilepsy care, highlighting both its potential and limitations, and underscores the ongoing need to adapt and refine this mode of healthcare delivery to better serve patients' needs.
Rohit Marawar, MD (Host): What if a doctor's visit no longer meant hours of travel or long waits in a clinic? For people with epilepsy, telehealth is redefining what access to care looks like. But is this shift here to stay? Today, we're unpacking the reality of telehealth and its growing role in epilepsy. Welcome to the Epilepsy Currents Podcast, an audio accompaniment to the Epilepsy Currents Journal, where we discuss the latest in epilepsy research and care.
I'm your host, Rohit Marawar. Joining us today are Dr. Anup Patel, pediatric neurologist, and Dr. John Stern, adult neurologist, both leaders in epilepsy and co authors of the recently published Epilepsy Currents Review article, The Tell on Telehealth, which explores the evolution of telehealth, the challenges, and its impact on epilepsy patients.
before we get started, a quick thanks to Mariners Pharmaceuticals, who is proud to sponsor this episode of Epilepsy Currents Podcast.
welcome both. Thank you for joining us.
Let's get started, Dr. Patel. So I was intrigued to learn from your review article that telehealth isn't [00:01:00] actually a new concept and has been around for more than two decades. Could you give us a brief rundown of how telehealth has evolved over the years? And what led you to write this review article?
Anup D. Patel, MD: that's a really great question. I think one of the things when we, started to look into this area as an opportunity that obviously became more available during the COVID 19 pandemic, we realized that others have been using telehealth and like you said for about 20 years, but I think the evolution really exists in the technology advances that we've had to make easier for us to actually do telehealth with a video in a safe but secure environment.
I think the other big advantage obviously was the tipping point that occurred, and, during the COVID 19 pandemic. And what we recognize as an author group was that, there was not as much guidance as we needed or would want as it relates to telehealth visits, specifically The other thing is there's more than just a video [00:02:00] visit, which became obviously commonplace during the pandemic.
The other advances, obviously, because of the pandemic was like the restrictions around reimbursement were reduced. And we'll talk more later in this episode about some of the licensure changes, but it was pretty open at that time, which allowed us to be able to access this technology to help improve or continue to maintain patient care.
Rohit Marawar, MD (Host): Dr. Stern, why do you think telehealth has become such a crucial service for people with epilepsy?
John M. Stern, MD: think an obvious part of the answer is the driving restrictions that people have who don't have seizure freedom and have epilepsy. think that's really only a small part of the importance because thankfully most people with epilepsy are seizure free. And the issue really becomes a matter of access because care for epilepsy has become much more sophisticated.
It's required more specialized understanding. And Physicians who can provide that are not commonly distributed across the United States, so it's a matter of distance and access more than [00:03:00] drivability, in my mind, why it's so important, because you wouldn't want people, because of geography, to not have access to physicians with the expertise who can provide better care for them, whether or not they're seizure free.
And this, in fact, maybe is no different for other conditions. beyond epilepsy. Whereas healthcare in general is shifting with this catalyst of COVID 19 to allowing people who are not geographically well situated for expertise to not be denied those opinions.
Rohit Marawar, MD (Host): And again, Dr. Stern, when we compare outcomes for epilepsy patients who use telehealth versus those who have in person visits, what does the data show? Are there any major differences?
John M. Stern, MD: have questions about the data because it comes down to the question of the outcomes and it comes down to, as well, how do you ascertain the outcome? people like telehealth because of the convenience, and that goes for both doctors and patients, but telehealth is not, perfect, and there are definitely problems that arise with telehealth care, which [00:04:00] we'll talk about, and so if the outcome is appreciation If we can't do this without availability and ability to communicate effectively, then telehealth can do very well.
But, we need to be cognizant of telehealth being part of care delivery, and in my opinion, it's never going to replace in person visits because of the specific needs Benefits of being present with a person is two people.
Rohit Marawar, MD (Host): Dr. Patel, kind of building on that, which type of patients do you think might be better suited for in person visits rather than a telehealth visit?
Anup D. Patel, MD: Yeah, I think some of the research that we did and review of the literature showed that, you know, perhaps new patients would be better served, as being seen in person. I think that the other big thing is if there are motor and other, specific, um, Concerns around movement changes and for follow up patients, those would be better served in person.
One of the challenges that we have with video telehealth is exactly picking up some of those [00:05:00] nuances, in the exam format. But otherwise, you know, there are a lot of advantages like Dr. Stern mentioned to the telehealth visit?
and most of the epilepsy follow ups, you know, obviously the exam isn't going to be as helpful.
So in those situations, telehealth might be a little bit more ideal, but. Beyond that, you know, like Dr. Stern said, the other area that really favors inpatient is if you have a neurostimulation device, to be able to interrogate or evaluate that device, it really needs to obviously be in person in this present day.
Now that may change with some of the technological advances on the horizon, but as of now, those patients should be seen at least once a year, if not more, inpatient for that device interrogation.
Rohit Marawar, MD (Host): Makes sense. Dr. Patel, your article includes a comprehensive table on how to conduct a successful telehealth visit. Could you share some key considerations and maybe a few tips from your personal experience that have made your telehealth appointments run smoother?
Anup D. Patel, MD: Yeah, and I think [00:06:00] we've learned a lot in this area. I think that the assumptions we had made earlier, around everyone's ability to access broadband internet or at least have a stable connection is flawed. So I think one of the things I would recommend and it's like a highlight of in the table is that that's a key consideration, you know, making sure your patient and their caregivers obviously have access, that can log on.
Plan ahead. You know, I think we, assume people are going to be able to log on without any technological difficulties, but that is not necessarily always the case. So, you be prepared, for that situation by going ahead and planning ahead. I think the other things that are good key considerations that we highlighted was just really being cognizant of, how to run the examination.
So we provided some and trades of where, there's been some literature around doing a virtual exam and what are some of the pearls and opportunities in that sense. And I think the last thing is that we also highlighted was don't forget that the educational [00:07:00] materials that you would normally provide in person should also be provided some mechanism this virtual model.
And so, you know, whether that's uploading in your electronic health record and sending through the patient portal or mailing it to them, be cognizant and aware that those are some gaps. And so we'll make your visit a lot more successful.
Rohit Marawar, MD (Host): Dr. Stern, telehealth does present some barriers like challenges in completing quality scales for screening comorbidities or conducting a neurological exam. what solutions are available currently to overcome these obstacles?
John M. Stern, MD: at the risk of sounding simplistic, think the best solution is not to use telehealth, because the situations where telehealth is not optimal for the care is a situation where really there should be effort to make it an in person visit because I believe that both types of visits have definite value.
beyond what Dr. Patel just discussed, recognize more and more that the technologic obstacles are not just on the patient's side, they can be on the. Physician side, as even an [00:08:00] institution, a large hospital or university will have sometimes problems with intranet. And then as computers get updates for the operating systems, that also can create a problem.
And so, these become barriers to successful communication. It's really on our side, not the patient's side. The other part of it is, the communication. when the patient is doing well, And it's a matter of check in and reviewing a few basics. telehealth can do, serve very nicely, but when the communication has to be more nuanced and get into subtleties and much more focused toward, understanding, in person really provides a much better means for that.
And I think that's partly because of distraction. I see sometimes patients who are in telehealth, but although I get to see them in their own environment, which can be helpful, it also means all the distractions of their home environment are there. And having a room where it's just, the doctor and the patient, maybe the patient's family is a way of providing that focus, which can be really important for better understanding.
And the understanding is bilateral. My [00:09:00] understanding of the patient and the patient's understanding of me. And so when there's. Meaningful conversation that's needed sometimes in person is much better. In the same way, as an analogy, video provides better communication than just audio. I mean, the telephone encounter, my experience doesn't give the same level of communication as a telehealth video encounter and being present, adds to it as well.
think the problem can arise that sometimes one doesn't know ahead of time whether that visit really requires that level of communication. There has to be a continual attention to maybe, should the next visit be tele or should the next visit be in person as a way of paying attention to not convenience, which definitely there, but to what we're trying to achieve in making the best possible decision.
Rohit Marawar, MD (Host): Dr. Stern, can you update us on what kinds of telehealth services are currently allowed, including the type of visits, locations, and billing considerations?
John M. Stern, MD: the medical legal part of this is all [00:10:00] in flux because the world's changing. And a lot of this depends upon Medicare and federal oversight, and then it also depends on the individual states and whether the states allow for care across state boundaries. This is where we in the United States have both an advantage and a disadvantage, that we have, uh, The opportunity for different systems of care to be delivered, but then it's a question of how does that get brought together when we don't think about boundaries between states as being so important as we go about our days.
The approval for telehealth has, end dates, but it's so far been continually re approved. and extended. My expectation for what it's worth is that telehealth is here to stay for the obvious benefits that it provides, and so it's going to come down to some type of indefinite approval with more clear understanding as to boundaries among the states.
There are already arrangements across many states that allow for telehealth in terms of reciprocal arrangements, but I would say whatever I would say for today may not be true for when a [00:11:00] viewer watches this recording, and so The onus is on all of us to stay current for what's allowed and leverage the resources of our institutions to keep on top of that for us.
Rohit Marawar, MD (Host): And uh, Dr. Patel, what should physicians keep in mind regarding licensing and malpractice when providing telehealth services?
Anup D. Patel, MD: I think the biggest thing is to build on what Dr. Stern mentioned is just to stay, on top of The ever changing landscape as it relates to this subject. Use your institution or your business manager to make sure the, malpractice part is covered, which usually is and not as big of an issue.
The biggest opportunity really is understanding how your state is. There are a variety of terms that this allows for video telehealth or other forms of telehealth. Dr. Stern alluded to this that some states are a little bit more flexible in allowing patients to live in different states and access you from, you know, in a different state than they are currently living in.
But many others do not. And so, if you have a large population, percent of [00:12:00] patients who live in another state that you feel would benefit from video telehealth, consider actually getting a license to practice medicine for that state. I know that's what we've done in the Midwest And Ohio specifically because some of the borderline states we draw patients from with video telehealth.
but having a West Virginia, Indiana, or Kentucky license is definitely a benefit to many of our providers. During the pandemic, we were able to have exceptions in that regard that allowed for, again, the optimal care to be continued or even delivered. That did change. And so now don't assume that you're able to do a visit for someone who lives in a different state.
Check ahead. Be proactive, but more importantly, if you do again, have a large population, consider just getting the license for that state. It will save a lot of headaches down the road.
Rohit Marawar, MD (Host): And finally, Dr. Stern, you answered this somewhat, but what do you see as the future of telehealth in terms of legislation, compensation, and its role in clinical care, especially in epilepsy?
John M. Stern, MD: [00:13:00] expect legislation to be placed that allows for telehealth to be indefinite and a part of healthcare delivery. I expect compensation to be more nuanced for what's being delivered because that's the history of compensation is to think about what effort and risk and resources are needed to deliver the care and it's different for in person than telehealth.
But the role in clinical care, that's an exciting question because you're asking to look into the future, and although remarkable how much change has occurred in the past five years or so, those changes are all extensions of what we already had somewhat for video meetings which we've had outside of clinical care.
The question is whether clinical care might become more important. More specialized within the telecommunication world, and I wonder about two parts of this. one is we're thinking about accessing specialists, where geography is really the limitation, but access requires something more than just a meeting like we're having today.
Whether there could be satellite offices that provide [00:14:00] resources for telehealth. And I'm imagining ways of doing the exam or maybe assistants who are trained in those offices, where the physician's not there, but the person goes to a facility much closer to where they live than the actual hospital and gets something that's a bridge where it's not really at home, but nor is it going to the place of that specialist and has an encounter that Provides, a solution to some of the obstacles that are present now through the assistance of somebody, who's a, a nurse or, another trained, caregiver.
I also wonder about telehealth in, the sense of not just the encounter, but, remote patient monitoring. You know, what happens when a patient, especially with epilepsy, where the condition can fluctuate, but other conditions do the same, and world in the future is very likely to have devices that help.
So, in gathering the information that's useful for care planning, and this information might be available or should be available to the provider at a distance, where maybe [00:15:00] the telehealth is continual, not just episodic visits. And so, the telehealth in that sense of the term telehealth is the physician, maybe the epileptologist in this case, having a way of tracking how patients are doing, maybe flags come up for when changes occur, and that triggers a visit to discuss that.
And may allow for better outcomes because it's more immediate than the scheduled visit. I'm going to see you in four months, no matter what, and it's becoming, molded to the actual patient need.
Rohit Marawar, MD (Host): I think that makes great sense. that wraps up our discussion on telehealth and epilepsy care. A big thanks to Dr. Patel and Dr. Stern for sharing their insights from the review article, The Tell on Telehealth. If you enjoyed this episode, please subscribe, share, and leave a review. You can find more episodes of epilepsy currents wherever you listen to your podcasts.
Thank you to our sponsor of this episode, Marinus Pharmaceuticals. Marinus is dedicated to the development of innovative treatments for rare genetic epilepsies, including CDK five [00:16:00] deficiency disorder. The company is committed to collaborating with epilepsy experts to advance therapeutic options that support the work of physicians and make a meaningful difference in patients' lives.
Learn more at marinuspharma.com.